Educational Principles of Simulation-Based Procedural Training

Ganesh Srinivasan

The Need

The traditional see one, do one, teach one, and hope not to harm one Halstedian model of graduated responsibility for acquisition of procedural skills has been termed “education by random opportunity.” Rationing of work hours during residency training, the increasing breadth of technical skills required in neonatology, and the limited opportunity to acquire competence in the context of safety and time provide us with both a challenge and an opportunity to revisit traditional training and embrace innovative learning strategies.

The educational strategies best suited to address acquisition of procedural skills include didactic, audiovisual, simulated experiences and supervised clinical experiences with coaching and feedback.

Simulation enables repeated procedural exposure in a safe environment without compromising patient safety, that is, see a lot, simulate and train a lot, teach and assist a lot, and harm none (1, 2, 3, 4, 5, 6, 7, 8, 9, 10). Although animal and other models have been used to teach and practice procedures used in neonates for the past 4 decades (Fig. 1.1A-E and Table 1.1) (3, 8), the role of simulation-based training has made a paradigm shift in the past 20 years to an educational experience that helps address the need for integrated acquisition of technical skills, behavioral skills (including ability to work as part of a team), and cognitive skills—factors where deficits identified and not corrected may lead to adverse outcomes. The Neonatal Resuscitation Program™ has embraced simulation-based resuscitation training methodology to teach and evaluate competence in neonatal resuscitation (12). The recent advances and availability of virtual reality and augmented reality in addition to high fidelity simulators hold promise in advancing our goal of improving safety and quality for all while performing procedures. This chapter serves as a general overview of the current underlying educational principles of simulation-based training in neonatology (13, 14, 15, 16, 17, 18).

The Theory of Simulation-Based Learning

Bloom’s Taxonomy

According to Bloom’s taxonomy of learning (Fig. 1.2), knowledge and comprehension are the simplest levels of learning. Simulation, when used with the goal of improving practice, can allow the learner to move from knowledge or comprehension to application, analysis, and synthesis, which are better indicators of competence.

Adult Learners

1. Are self-directed and self-regulated in their learning

2. Are predominantly intrinsically motivated to learn

3. Have previous knowledge and experience that are an increasing resource for learning

4. Through this previous experience, they form mental models that guide their behavior

5. Use analogical reasoning in learning and practice

The process of having an experience (concrete experience), reflecting on the experience (reflective observation),

developing mental models (abstract conceptualization), and testing that mental model (active experimentation) is based on Kolb’s experiential learning cycle (Fig. 1.3).

FIGURE 1.1 Teaching models (A) a ferret is used to demonstrate endotracheal intubation. B: An infant intubation model (Resusci Intubation Model, Laerdal Medical, Armonk, NY) is used to practice endotracheal intubation. A viewing port in the back of the head allows demonstration of anatomic relationships. C: A rabbit’s ear has been shaved to demonstrate vessels for intravenous placement. D: A resuscitation model (Resusci Baby, Laerdal Medical) is used to practice bag and mask ventilation. E: An umbilical cord is used to practice catheter insertion. The cord is placed in an infant feeding bottle, filled with normal saline, and supported inside a cardboard box. The end of the cord projects through a cut nipple. (Reprinted with permission from MacDonald MG, Seshia MMK. Neonatology: Pathophysiology and Management of the Newborn. 4th ed. Philadelphia, PA: JB Lippincott; 1994.)

TABLE 1.1 Teaching Models Used to Teach Procedures

Manikin (Small Dolls with Soft Vinyl Skin) To teach tracheotomy care:
	Create a hole in the doll’s neck with a sharp instrument—a corkscrew works well. Insert a size 1 or size 0 tracheotomy tube. Tie the ties, and use as a model to teach proper suctioning and skin care techniques.
To teach umbilical catheter management:
	Puncture the doll’s anterior abdomen using a 16-gauge Medicut needle. Insert needle through the doll’s front and back, then remove. Thread an umbilical catheter through from front to back. Insert blunt needles onto catheter at both ends. An IV bag containing water tinted with red food coloring can be attached to the posterior end of the catheter to simulate blood.
To teach technique for drawing samples for blood gases:
	Insert a three-way stopcock into the umbilical catheter anteriorly and attach IV bag and tubing.
This system also can be used to teach arterial and venous blood pressure monitoring by transducer.
	To simulate arterial pressure, wrap a blood pressure cuff around the partially filled IV bag and inflate to 60-70 torr. For a venous line, inflate to 5-10 torr.
Resusci Head^a The model head used for endotracheal intubation can be modified to teach orogastric and nasogastric feeding by attaching a reservoir to the esophageal opening.
Rabbits To teach placement of chest tube:
	Anesthetize a rabbit weighing approximately 2 kg using xylazine, 8.8 mg/kg IM. Wait 10 min, then administer ketamine HCI, 50 mg/kg IM. Place the rabbit on its back and shave or clip the chest hair as closely as possible. Use a commercial depilatory to remove remaining hair. Restrain the rabbit’s fore- and hindpaws securely. Surgically drape the rabbit. Place electrodes on the chest wall for attachment to a cardiorespiratory monitor. Changes in ECG tracing due to the pneumothorax can then be demonstrated. Insert chest tube.
Weanling Kittens To teach endotracheal intubation:
	Use kittens weighing 1-1.5 kg. Withhold food 8 h before intubation; however, allow water intake. Give ketamine HCI 20 mg/kg IM. Wait 10 min for full effect of ketamine HCI.
Examine larynx after every four or five attempts at intubation. If the laryngeal area is traumatized, allow 7-10 d for recovery.
Ferrets To teach endotracheal intubation
	Withhold food 8 h before intubation; however, allow water intake. Give ketamine HCI, 5 mg/kg IM, and acepromazine maleate, 0.55 mg/kg IM, and allow to take effect. Maintain anesthesia with 40% of original dose IM as needed. If necessary, control sneezing with 0.5 mg/kg IM of diphenhydramine. Apply bland ophthalmic ointment to eyes to prevent desiccation.
Examine larynx for signs of trauma, as for kittens, and allow recovery between training sessions. Evidence of trauma was noted in 100% of ferrets after 10 intubations.
Placenta and Cord To teach insertion of IV infusion lines and umbilical vessel catheters^b:
	Preserve placenta and cord by freezing in individual containers. Allow 3-4 h for thawing before use. Use vessels on the fetal surface of the placenta to demonstrate insertion of peripheral IV needles and cannulae. Blood drawing also can be demonstrated. Cut a 15-cm length of cord to demonstrate the anatomy of the umbilical stump and the technique for arterial and venous catheterization. The cord may be placed in an infant’s feeding bottle that contains saline. One end of the cord then protrudes through a suitably cut nipple and can be pulled out of the bottle for each attempt at the procedure.
^aLaerdal Medical, Armonk, NY. ^bUse of this model is not recommended unless HIV and hepatitis B virus status of source is known.
Reprinted with permission from Avery GB, MacDonald MG, Seshia MMK. Avery’s Neonatology: Pathophysiology and Management of the Newborn. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1994.

FIGURE 1.2 The older and newer versions of Bloom’s taxonomy in the cognitive domain. (Reprinted with permission from Timby BK. Fundamental Nursing Skills and Concepts. 11th ed. Philadelphia, PA: Wolters Kluwer; 2016:109.)

FIGURE 1.3 Kolb’s experiential cycle forms the basis for adult simulation-based education. (From Kolb A, Kolb D, Experience Based Learning Systems. Australian Educational Leader. 2018;40(3):8-14. https://learningfromexperience.com/downloads/research-library/eight-important-things-to-know-about-the-experiential-learning-cycle.pdf. Accessed July 11, 2019.)

Kolb’s Experiential Learning Cycle

1. Concrete experience (feeling): Simulations provide concrete experiences that stress the learner, causing a significant change of body state to foster meaningful reflection of learner identified knowledge gaps.

2. Reflective observation (watching): Debriefing provides the opportunity for learners to reflect on the simulation and their performance. The learner observes before making a judgment and seeks optimal comprehension by viewing the experience from different perspectives. The educators can facilitate the process by providing an objective view of the learner’s performance.

3. Abstract conceptualization (thinking): Is the logical analysis of ideas and acting on intellectual understanding of a situation by the learner, and helps provide the educator with the opportunity to clarify the same. This results in a new mental model and understanding.

4. Active experimentation (doing): This new mental model and understanding, developed by the learner, requires immediate testing by active experimentation, in order to imprint new knowledge and effect longterm changes in practice.

5. Depending on the situation or environment, the learner may enter the learning style at any point and will best learn the new task if they practice all four modes in Kolb’s cycle.

For example, learning to place a radial arterial line:

Reflective observation: Thinking about placing a radial

line and watching another person place a line

Abstract conceptualization: Understanding the theory, indications and contraindications, hand washing and safety, and having a clear grasp of the concept

Concrete experience: Receiving practical tips and techniques from an expert

Active experience: Getting the opportunity and attempting to place a line under supervision

Procedural Skill Learning

Sawyer et al. have built on Kovacs psychomotor learning theory paradigm of Learn, See, Practice and Do and suggested a pedagogical framework incorporating two additional steps Prove and Maintain for the learner (19, 20, 21, 22) (Fig. 1.4).

1. Learn the procedure and acquire requisite cognitive knowledge

2. See the procedure performed by instructor or preceptor

3. Practice the procedure with emphasis on error free deliberate practice and distributed practice

FIGURE 1.4 The progression of the development of expertise in procedural skills using Simpson’s and Harrow’s taxonomy of psychomotor skill development correlated with the Dreyfus and Dreyfus lexicon of medical skill acquisition. (Reprinted with permission from Sawyer T, White M, Zaveri P, et al. Learn, see, practice, prove, do, maintain: An evidence-based pedagogical framework for procedural skill training in medicine. Acad Med. 2015;90(8):1025-1033.)

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